BUILDING HEALTHY COMMUNITIES IN THE SAN JOAQUIN VALLEY:
PRELIMINARY BASELINE DATA REPORT
Melanie Briones, MPH
Armando Cortez, BS
John Capitman, PhD
MARCH 2010
1
Purpose
This report is intended to support the ongoing planning efforts of The California Endowment Building Healthy
Communities (BHC) sites in the San Joaquin Valley by beginning a regional conversation about currently
available data and additional data needed to support planning and implementation of the BHC strategic
initiatives. Because the planning process is ongoing, it is premature to discuss long-term evaluation of the
efforts in the region or statewide. Rather this report is intended to help planners think more about the
objectives, strategies, and indicators they are considering in their plans ---where our communities are now and
how to conceptualize the impacts being sought. We encourage Building Health Communities planning initiative
in the region to contact CVHPI to discuss how the data and issues we present or other ways we may be able to
assist your community initiatives.
Background
The San Joaquin Valley (SJV) is home to three of The California Endowment’s (TCE) fourteen Building
Healthy Communities (BHC) sites: Central Fresno, South Kern, and South Merced. Community members and
other stakeholders are now deeply engaged in developing initial phases of long-term plans for meeting the TCE
“Four Big Results” and “10 Outcomes” over the next 10 years. In developing the BHC initiatives, TCE has
sought authentic community engagement in understanding how the Four Big Results can be achieved and so the
specific outcomes each community will pursue will be adapted to local contexts. In a similar way, the specific
outcomes each site pursues will be shaped by local conditions, the broader outlines of their long-term plans, and
how outcomes are linked to the Big Results. In this context, it is way too early to articulate the set of indicators
that will be used for program accountability and evaluation. Nonetheless, as the three San Joaquin Valley BHC
collaboratievss develop long-term strategic plans, they are seeking ways to frame their objectives, strategies and
indicators. Articulating indicators of community baseline performance, interim progress and demonstrable
impact relative to the Big Results and specific outcomes is emerging as a key component of these discussions.
Even while TCE continues to articulate a statewide framework for measuring the impact of the BHC program, it
will be helpful for SJV BHC site planners and others in our region to engage in a more comprehensive
discussion of how we can measure our current status and what we would propose as indicators of progress and
achievement.
Data Measures
The Central Valley Health Policy Institute, California State University, Fresno (CVHPI) is collaborating with
other BHC participants in the region to assess the existing data capacity to measure the baseline and progress of
the TCE “Four Big Results”. CVHPI has sought to identify data elements to measure and approximate these
“Four Big Results” and “10 Outcomes”. We also collaborated with TCE’s Office of Research and used data
elements that they have been developing where possible. Table 1 lists each of the “Four Big Results” and their
3-5 supporting Outcomes. Note that TCE has attributed multiple outcomes to each Big Result but some of these
outcomes are associated with two or more of the Big Results. In order to avoid presenting an overly
complicated and lengthy report, we present preliminary baseline measures for eight of the ten outcomes. We
organize this presentation around the Big Results and we note how specific outcomes may be understood or
measured differently in the context of each result with which it is associated. These preliminary baseline data
sources are proposed here as starting points for future data conversations and to assist planners at each of the
Valley sites conceptualize goals, strategies, and indicators.
While data measures were sought for all concepts, the following data are not intended to represent an exhaustive
presentation of all appropriate data. Table 2 provides potential indicators for each of the 10 Outcomes.
Selected data measures were primarily identified based on geographic criteria (e.g., zip code). Therefore, we
2
excluded measures that were only available at the county level. The following data presented in this report
were largely drawn from data sources readily identified and collected at the zip-code level and identified as
acceptable measures for each Big Result and its associated outcomes. We defined the area included in each
TCE place using the census boundaries, zip codes, and schools as identified by TCE. In addition, we draw on
findings from a recent community telephone survey to indicate the kinds of measures that could potentially be
drawn from targeted new data collection (Table 3) as well as through in-house analysis of existing data (Table
4). For more detail on the data sources used, please see Appendix A.
3
Table 1: TCE-BHC Four Big Results and Associated Outcomes
Indicators of Achievement
Big Result #1
Provide A Health
Home for All Children
Direct
Outcomes
Indirect
Outcomes
Big Result #2
Reverse The
Childhood
Obesity Epidemic
Direct
Outcomes
Indirect
Outcomes
Big Result #3
Increase School
Attendance
Direct
Outcomes
Indirect
Outcomes
Big Result #4
Reduce Youth
Violence
Direct
Outcomes
Indirect
Outcomes
» All children have health coverage (Outcome 1)
» Families have improved access to a health home that supports healthy behaviors (Outcome 2)
» Health and family-focused human services shift resources toward prevention (Outcome 3)
» Neighborhood and school environments support improved health and healthy behaviors (Outcome 7)
» Health gaps for boys and young men of color are narrowed (Outcome 9)
» California has a shared vision of community health (Outcome 10)
» Neighborhood and school environments support improved health and healthy behaviors (Outcome 7)
» Residents live in communities with health-promoting land use, transportation and community development (Outcome 4)
» Health and family-focused human services shift resources toward prevention (Outcome 3)
» Communities support healthy youth development (Outcome 6)
» Families have improved access to a health home that supports healthy behaviors (Outcome 2)
» California has a shared vision of community health (Outcome 10)
» Families have improved access to a health home that supports healthy behaviors (Outcome 2)
» Neighborhood and school environments support improved health and healthy behaviors (Outcome 7)
» Health gaps for boys and young men of color are narrowed (Outcome 9)
» Health and family-focused human services shift resources toward prevention (Outcome 3)
» Residents live in communities with health-promoting land use, transportation and community development (Outcome 4)
» Communities support healthy youth development (Outcome 6)
» Children and their families are safe from violence in their homes and neighborhoods (Outcome 5)
» Communities support healthy youth development (Outcome 6)
» Community health improvements are linked to economic development (Outcome 8)
» Health gaps for boys and young men of color are narrowed (Outcome 9)
» Neighborhood and school environments support improved health and healthy behaviors (Outcome 7)
» Health and family-focused human services shift resources toward prevention (Outcome 3)
» California has a shared vision of community health (Outcome 10)
» Residents live in communities with health-promoting land use, transportation and community development (Outcome 4)
4
Table 2: Available Data Measuring TCE-BHC 10 Outcomes
Big Results and Outcomes
Big Result #1
Outcome 1 - All children have health coverage
Possible Data Sources
Years of Potential Life Lost (YPLL) data
Big Results #1 & #3
Outcome 2 - Families have improved access to a health home
that supports healthy behaviors
Big Results #1 & #2
Outcome 3 - Health and family-focused human services shift
resources toward prevention
Big Result #2
Outcome 4 - Residents live in communities with health-promoting
land-use, transportation, and community development
Big Result #4
Outcome 5 - Children and their families are safe from violence
in their homes and neighborhoods
Big Result #4
Outcome 6 - Communities support healthy youth development
Big Results #2, #3, & #4
Outcome 7 - Neighborhood and school environments support
improved health and healthy behaviors
Big Result #4
Outcome 8 - Community health improvements are linked to
economic development
Big Results #3 & #4
Outcome 9 - Health gaps for boys and young men of color are
narrowed
Big Result #3
Outcome 10 - California has a shared vision of community health
5
Avoidable hospitalizations - Adult & Pediatric
Community Survey - Self-Efficacy
Community Survey - General Well-Being
Avoidable hospitalizations - Adult & Pediatric
Community Survey - Depression
Community Survey - Diagnosed Chronic Conditions
Community Survey - Civic Engagement
Community Survey - Collective Efficacy
Intentional violence - Adult & Youth
Community Survey - Neighborhood Disorder
Community Survey - Neighborhood Quality
Community Survey - Civic Engagement
Community Survey - Collective Efficacy
Community Survey - Neighborhood Disorder
Community Survey - Neighborhood Quality
Community Survey - Self-Efficacy
Community Survey - General Well-Being
Fitnessgram - % Healthy BMI
High school/middle school annual drop outs by gender
Community Survey - Depression
Community Survey - Diagnosed Chronic Conditions
Community Survey - Neighborhood Quality
Unemployment Rates
Employment Opportunities
Table 3: BHC Community Cluster Survey Analysis
Demographics
Average sample size (n)
Fresno
120
Kern
120
SJV Average
1000
37.2 (10.4)
71.0
34.2
34.8
17.7
37.9 (13.5)
71.0
50.3
43.2
28.9
39.5 (12.5)
72.8
42.5
33.4
23.6
70.3
2.4
47.9
3.9
57.4
3.9
61.9
69.2
96.9
62.3
76.9
93.0
65.3
70.9
91.1
17.3
15.8
23
42.1
24.8
25.9
20
27.1
24.8
84.8
14.4
80.6
15.5
81.9
13.3
14.4
3.1
4.3
35
50
29.7
42.4
32.5
37.6
59
54
56
Fruit and Vegetable Intake
Fruits < 5/previous 7 days (%)
Vegetables < 5/previous 7 days (%)
38.9
24.8
36.6
37.2
38
32.1
Neighborhood Environment
Disadvantage Scale
0 (%)
1-3 (%)
4+ (%)
9.8
64.1
26.1
10.2
42
47.7
13.9
50.8
35.4
20
34.4
24.8
Age (yrs) - [mean (SD)]
Female (%)
Hispanic (%)
Income < $20,000/household/year (%)
Education < 12 years (%)
Social Connectedness
Married/Living with partner (%)
Socially isolated (%)
Civic engagement score (% Never attended)
» Town or school meeting
» Club or organization (Not for work)
» Regional problem group
Overall Health
General well-being
Fair or Poor (%)
No physical in past year (%)
Depression score (0 - 5 high depression score)
% High depression score (>= 3 / 5)
Chronic conditions diagnosed
At least 1 (%)
2+ (%)
Self-Efficacy Score
Low Self-Efficacy (%)
Health Behaviors
Obesity
≥ 25 BMI < 30 (%)
BMI ≥ 30 (%)
Physical Activity
2 or fewer days of moderate physical activity
in last week
Safety (1 - 5 most unsafe)
% Score: 2-5
6
Table 4: CVHPI Data Warehouse – SJV BHC Sites
Population
% of County Pop
Pop Density
Median Income
% Families below FPL
% Non His
% His
% Pop >55
% House w/ child
Fresno
BHC
County
95,648
926,508
10%
5393.0
151.0
$22,878 $47,298
43.5%
17.2%
30%
51%
70%
49%
12.8%
18.8%
58.9%
45.9%
BHC
66,156
8%
678.0
$25,017
23.1%
21%
79%
11.0%
47.0%
County
821,705
97.0
$47,105
15.9%
52%
48%
17.2%
47.0%
Merced
BHC
County
61,725
254,726
24%
442.0
127.0
$36,091 $44,410
29.0%
16.7%
38%
47%
62%
53%
17.0%
17.9%
47.0%
50.5%
High School
Drop out %, (2007-08)
Male
Female
Total
8%
6%
7%
5.2%
4.9%
5.0%
6%
4%
5%
7.9%
5.6%
6.8%
3%
2%
3%
Middle School
Drop out %, (2007-08)
Male
Female
Total
2%
1%
1%
1.3%
1.0%
1.1%
0%
1%
0.5%
3.3%
2.9%
3.1%
61.6%
66.2%
64.2%
15.0%
2552
15%
8.0%
16902
per 100,000
per 100,000
5,308
58.16
12.36
16.0
15.9
26.86
per 10,000
per 10,000
167.25
37.52
Data Measures, years
Demographics, 2009
% Healthy Zone BMI, 2006
for 5,7,9 grade children
Unemployment rate, 2006
Payroll Establishments
Death Count, (1999-2005)
YPLL (65)
YPLL (25)
LE (65)
Intentional Mortality Age 0-24
Intentional Mortality All
Avoidable Hosp Rate, (98-06)
Pediatric Avoidalbe Hosp Rate
Annual Average
% of County total
YPLL per 1000
YPLL per 1000
Kern
SJV
CA
3,963,149
37,074,881
1970.0
$44,766
16.3%
52%
48%
18.4%
47.0%
234.4
$49,894
4.7%
3.7%
4.2%
5.9%
4.4%
5.2%
4.4%
3.3%
3.9%
0%
0%
0%
0.9%
0.7%
0.8%
1.5%
1.2%
1.3%
0.9%
0.9%
0.9%
65.2%
75.0%
66.0%
12.7%
1339
12%
7.6%
11467
10.0%
1321
35%
9.4%
3769
7.9%
64385
4.9%
38,162
41.44
10.94
18.0
9.7
15.51
3,963
57.02
13.18
16.2
12.2
20.3
35,053
44.80
11.22
16.6
9.4
17.43
4,789
45.86
11.52
16.1
14.1
20.29
9,689
40.95
10.31
17.4
10.5
15.33
169,424
42.47
10.73
17.5
9.6
15.7
1,604,475
29.26
8.55
18.7
10.1
15.5
140.02
27.94
148.28
18.00
165.18
17.47
155.23
15.34
138.90
18.22
154.28
21.51
7
64%
36%
19.7%
38.0%
67.4%
Results and Findings
Big Result #1: Provide a Health Home for All Children
Related Outcomes and Preliminary Baseline Measures
Outcome 1: All children have health coverage
In the context of child access to a health home, a specific measure of whether or not all children in the
Valley BHC places have health coverage is not currently available. Through TCE efforts, California
Health Interview Survey data for the BHC places will be available in the future. Institutional data on
population enrollment or survey data on individuals’ perceived coverage and access may be required.
Indirect measures of adequate access to health care were sought.
YPLL (25) rate – Years of potential life lost up to age 25 per 1000 population. This is an alternate
version of the YPLL 65 indicator. YPLL 25 highlights deaths that occur between 0-25 years old. In this
way it can be seen if an area has issues with young people dying versus that of an older population dying
that is captured in the YPLL 65 indicator. YPLL25 is perhaps most impacted by perinatal mortality and
intentional mortality, yet it does provide an important summary of the health of children. High rates of
mortality for persons age 25 and younger may indicate the adquacy of their health care access.
o All three BHC sites have higher YPLL (25) than their respective counties.
Outcome 2: Families have improved access to a health home that supports healthy behaviors
In the context of child access to a health home, a specific measure of whether or not all families have
improved access to a health home that supports healthy behavior is not available. Both institutional data
on policies of health providers and utilization of preventive services along with survey data on percieved
access to prevention and preceived support for healthy behaviors may be required. Indirect measures of
adequate access to preventive health care were sought. We also identified possible survey indicators of
access to preventive care and perceived support for healthy behaviors.
Pediatric avoidable hospitalization rate – The number of pediatric (0-19 age) avoidable
hospitalizations per 10,000 persons. A pediatric avoidable hospitalization is categorized as a
hospitalization that could have been avoided if age-appropriate primary and preventative care had been
accessible to patient in the period prior to the hospitalization. (A full list of conditions used in this
indicator is available in Appendix B.) The rate of avoidable hospitalizations in an area is one way to
determine if the population in that area has reasonable access to preventative care. Improving access a
family has to preventative care, or a health home, will support healthy behaviors and ultimately lower
the rate of avoidable hospitalizations.
o Fresno and Kern BHC sites have higher rates of pediatric avoidable hospitalizations than
their respective counties while Merced BHC site has a lower rate.
Self-efficacy – This survey scale measures the degree to which the respondents believe they are capable
of performing in a certain manner to attain certain goals. The data table reports the percentage of those
respondents indicating low self-efficacy.
o Kern BHC respondents report a small percentage of community respondents indicating low
self-efficacy (3.1%) and is comparable to the SJV average. On the other hand, Fresno BHC
respondents report much greater percentage of community residents feeling low self-efficacy
8
(14.4%). The greater the percentage of household members reporting low self-efficacy is
troubling and counter-productive to achieving Outcome 2.
General well-being – Community respondents were asked to rate their overall health status as:
Excellent, good, fair, or poor.
o Fresno and Kern BHC had similar percentages of ‘fair or poor’ general well-being. Both
BHC sites reported less negatively than the aggregate clusters.
Physical in last year – Community respondents were asked if they had an annual medical physical
examination in the past year was asked
o Nearly half of Fresno BHC respondents report NOT having had a physical examination in
the past year compared to one quarter of Kern BHC respondents.
Outcome 3: Health and family-focused human services shift resources toward prevention
In the context of child access to a health home, a specific measure of whether or not health and familyfocused human services shift resources toward presevention was not available. Institutional data on
policies, resource allocation and utilization may be required. Survey measures of perceived access to
preventive services may be required as well. Indirect measures of adequate access to preventive health
care were sought. We also identified possible survey indicators of access to preventive care and
perceived support for healthy behaviors.
Avoidable hospitalization rate – The number of avoidable hospitalizations per 10,000 population. An
avoidable hospitalization is categorized as a hospitalization that could have been avoided if proper
preventative care had been administered prior to the hospitalization. (For a full list of conditions that
were used in this indicator refer to Appendix B)
o Both Fresno and Merced BHC sites have much higher rates of avoidable hospitalizations
than their respective counties while the Kern BHC site has a much lower rate of avoidable
hospitalization than the county.
LE (65) – Life expectancy for a person at age 65. This is an alternate version of the overall
life expectancy health indicator. LE (65) captures how much longer a person who is 65 can reasonably
expect to live. LE can be analyzed by sex to indicate potential disparities between males and females
o The Kern BHC site has similar LE (65) than its county, while both the Fresno and Merced
BHC sites have lower LE (65) than their respective counties.
YPLL (65) rate – Years of potential life lost up to 65 per 1000 population. Even though life expectancy
is slowly increasing YPLL 65 is used as a health indicator, instead of YPLL 75, because the 65 cutoff
has been the standard for many years and allows for not only comparison to past data but also
emphasizes deaths that occur during productive years of life.
o All three BHC sites have a higher rate of YPLL 65 than their counties.
Depression scale – Community Cluster Survey residents responded to a standard 5-point Depression
Scale. The results were analyzed to produce a depression scale ranging from 0 to 5 (a score of 5
indicating the highest depression score). Scores of 3 (mid-range) and higher were analyzed for the
Fresno and Kern BHC sites.
9
o Kern BHC (27.1%) had a higher score than Fresno BHC (20.0%) and was also higher than the
SJV aggregate score of 24.8%
Diagnosed chronic conditions - Community Cluster Survey residents reported whether a physician had
diagnosed them with the following chronic conditions: heart disease, high blood pressure, diabetes,
cancer, asthma, arthritis, and or depression. Analysis focused on the total number of chronic diseases a
person was diagnosed with.
o The majority (84.8% and 80.6% respectively) of both Fresno and Kern BHC residents
responded that they had been diagnosed with at minimum one of the listed chronic
conditions. Fresno had a higher reported percentage of BHC residents with at least one
chronic condition than both Kern BHC and the aggregate cluster communities.
o Overall, the remainder of respondents indicated two or more chronic conditions
Big Result #2: Reverse the Childhood Obesity Epidemic
Related Outcomes and Preliminary Baseline Measures
In measuring reversal of the childhood obesity epidemic, some specific indicators health status such as
BMI as well as nutritional and physical activity may be most relevant. . Through TCE efforts, California
Health Interview Survey data for the BHC places will be available in the future. While more
comprehensive data sources may be identified, available secondary data on measures of fitness for
children in selected grades provide an important perspective on obesity rates in the BHC communities.
Fitnessgram– Healthy Zone BMI was calculated by looking at 2006 Fitnessgram data for children in
grades 5, 7 and 9 in the schools TCE identified as serving each Valley BHC. Appendix C lists the
schools identified by TCE for which we had Fitnessgram data available. More recent data and data that
include more schoools may be available. The percentage of children who had age appropriate body
composition scores were population weighted from all schools within the BHC areas or known to serve
primarily students living in the BHC area. This is a direct relationship indicator; as the childhood
obesity epidemic is reversed more children will have body composition scores that are age appropriate.
o The Fresno and Kern BHC sites have Healthy Zone BMI rates that are slightly worse than
their counties and also slightly worse than the state number. However, the Merced BHC site
has Healthy Zone BMI much higher than the county as a whole.
Outcome 7: Neighborhood and school environments support improved health and healthy behaviors
In the context of obesity prevention, no specifc approach to measuring the extent to which
neighborhoods and school environments support improved health and health behaviors has been
identified. Institutional data on efforts to create and sustain health promoting environments, direct
measures of neighborhood environments (walkability assessment, CX3 measures) and suvey measures
of perceived environmental support for improved health and healthy behaviors may be needed. Indirect
measures were sought, including available data on child fitness, and survey data on percieved
neighborhood environment. Indicators examined in the context of children’s access to a health home,
depression and diagnosed chronic conditions, were also considered as possible baseline factors that
planners might explore.
Neighborhood Environment – Two measures of neighborhood environment were analyzed from the
Community Cluster Survey. The first measure indicates neighborhood disadvantage and the second
indicates neighborhood safety. The respondents reported on various instances of neighborhood
“disadvantage” and a scale was created to report a scale of increasing disadvantage. Neighborhood
10
safety was assessed in a similar manner and reported on a scale of 1 – 5 (a score of 5 indicating the most
unsafe neighborhoods). Indicators of perceived neighborhood environment and safety may be
particularly useful as community seek to understand how built environment and public safety policies
are interacting with local conditions.
o Fresno BHC reported the majority (64%) of its neighborhood disadvantage in the medium
range of the scale (between 1-3 indicators of disadvantage). Unfortunately, Kern BHC
reported its neighborhood disorder (47.7%) on the highest end of the scale with 4 or more
indicators of neighborhood disorder. Both BHC sites reported higher are higher than the
SJV aggregate clusters.
o Similar to the Neighborhood Disorder findings, Kern reported worse scores on the safety
scale (34.4%) compared to Fresno BHC (20.0%) and the Cluster aggregate (24.8%)
Depression scale – (see above description)
Diagnosed chronic conditions – (see above description)
Outcome 4: Residents live in communities with health-promoting land use, transportation and community
development
BHC planners may develop objectives and strategies that shape land-use, transportation and community
development as a central approach in overcoming the obesity epidemic. Direct indicators of health
promoting land-use, transportation and community development were not identified. Such measures
could be based on institutional data on policies and patterns of investment and survey data exploring
both behavior patterns and perceptions around policy making and community environments. We sought
indirect measures that speak to family behavior patterns around nutrition and physical activity. We also
examined a measure of civic engagement, seeking an approach to assessing the degree to which
community members experienced opportunities to shape land-use, transportation and community
development efforts to meet their goals around obesity reduction, public safety, schools and other
features.
Obesity and Fruit & Vegetable Intake – BMI scores were calculated from community residents
reported height and weight. Respondents were also asked to recall their consumption of fruits and
vegetables in the previous week.
o Both Fresno and Kern BHC have higher rates of overweight and obesity than the Valley as a
whole and both show relatively low rates of weekly vegetable and fruit intake. Kern BHC
reports lower consumption of vegetables than the Valley as a whole
Physical activity – Physical activity was measured from community residents’ self-reported
participation in moderate physical activity during the past week and the frequency of physical activity
o Both Fresno and Kern BHC sites have similar proportions of residents who report
participating in moderate physical activity less than 3 times in the prior week compared to
the Valley as a whole.
Civic engagement – Community Cluster Survey respondents answered questions pertaining to their
involvement in community meetings to address school, local, and or regional decisions in the past year
(not including work-related meetings).
11
o The vast majority of people in both Fresno and Kern BHC sites did not participate in any
type of community, town or school, club or organization, nor regional problem-solving
meeting.
Big Result #3: Increase School Attendance
Related Outcomes and Preliminary Baseline Measures
The third big result, increase school attendance, may be measured directly and it is also linked to
outcomes about health and human service provider focus on prevention, neighborhood development,
safety and other factors. Measures of neighborhood land-use, transportation, and community
development, access to preventive services, and other aspects of a supportive community environment
may be measured in somewhat different ways in the context of increasing school attendance. Secondary
data from the California Department of Education provides important measures of school attendance,
but do not provide detail of outcomes based on the child’s home location and do not provide qualitative
information on the health and development related policies and practices that may be among the causes
of school completion rates.
Education Data – Dropout and enrollment data were obtained from the California Department of
Education website www.cde.ca.gov/index.asp. School district enrollment and dropout raw counts by
sex and rates for 2007-08 were calculated from raw data for both middle and high schools within the
BHC areas or known to serve students living in the BHC area. The drop-out percentage reported here is
the number of middle or high-school students who drop out that year compared with total enrollment at
each school serving the place. This was selected instead of the CDE four-year cumulative drop-out rates
to allow comparisons of middle and high school. While this is a direct indicator of school engagement,
with higher school attendance associated with lower dropout percentages, it is at best an indirect
indicator of whether or not schools are creating health promoting environments that support regular
attendance.
o Kern and Merced BHC sites have slightly lower high school dropout rates than their counties
with Fresno BHC having a higher high school dropout rate than Fresno county. Moreover,
all three BHC sites also have high school dropout rates higher than the state with the Kern
BHC site being quite a bit higher.
o Fresno BHC male middle school dropout rates are higher than both the county and state.
While, Kern and Merced BHC sites show middle school dropout rates lower than the county
and state.
Outcome 9: Health gaps for boys and young men of color are narrowed
Reducing health gaps for boys and men of color may be a crucial component of a strategy to increase
school attendance, reduce obesity, promote neighborhood safety and other key results in the BHC
initiative. Measuring reductions in health gaps by race/ethnicitry and gender within the BHC places is
not supported by currently available data. Institutional measures of policies and practices linked to
reducing race/ethnicity and gender linked health inequities have also not been articulated to this point.
Improved survey data for the BHC places may be needed on a longitudinal basis to addres baseline and
progress around this objective.
12
Big Result #4: Reduce Youth Violence
Related Outcomes and Preliminary Baseline Measures
Outcome 5: Children and their families are safe from violence in their homes and neighborhoods
Both objective and perceived safety from violence at home and in the neighborhood are cited as key
components of strategies to improve youth engagement in prevention-focused health care, reduce youth
obesity, and improve academic outcomes. As a big result, reducing youth violence has been linked to
many of the outcomes discussed, although measures of prevention access or other factors may need to
be modified to reflect attention to violence prevention. While direct measures of safety were hard to
identify from available secondary data, several indirect indicators that may be of use to planners have
been identified.
Intentional Mortality rate Age All – The number of intentional mortalities per 100,000 population.
Intentional mortalities are categorized as both homicides and suicides. The number/rate of intentional
mortalities such as homicides and suicides in an area is one way to measure how safe a neighborhood is
from violence and how safe children and their families are in their homes.
o All three BHC sites have higher intentional mortality rates for all ages than their respective
counties.
Intentional Mortality rate Age 0-24 – The number of intentional mortalities per 100,000 people ages
0-24. Intentional mortalities are categorized as both homicides and suicides.
o All three BHC sites have higher intentional mortality rates for age 0-24 than their respective
counties.
Outcome 6: Communities support healthy youth development
No specific indicators of community support for healthy youth development were identified, either in
the context of promoting youth safety or other Big Results. Direct measures of the activities of
community organizations and informal relationships and activities may be needed to more accurately
assess community performance. An indirect measure, that we discussed already, provides some
indication of whether or not health care access and community conditions are adequate to avoid
prevention-sensitive acute illnesses and associate hospital use among young people.
Avoidable pediatric hospitalization rate – (see Outcome 2 description above)
Outcome 8: Community health improvements are linked to economic development
No direct indicators of how and how much of community economic development is linked to health
improvements have been identified in the context of violence reduction or other outcomes. Direct
indicators might reflect the incorporation of health language in general plans, assessments of health
focus in ongoing economic development initiatives, and direct observation of the impacts of economic
development projects on health promoting built environmemts. Despite the difficulties in identifying
these indicators, it appeared that for baseline discussions, having sense of unemployment rates and
employment potentials within the BHC communities could be a starting place for planning.
13
Unemployment Rate – 2006 data were gathered from the California Employment Development
Department (EDD) Labor Market Information Division. Unemployment data was calculated by
applying each area ratio for zip codes (2000 Census) to the County labor force data. It is an estimate
only and assumes levels of employment and unemployment remain constant. A lower unemployment
rate for an area will usually correlate to a higher degree of infrastructure, transportation and
community development being present.
o All three BHC sites have higher unemployment rates compared to their respective counties.
o All three BHC sites have a higher percentage of county payroll establishments than they have
a percentage of county population.
Payroll Establishments – 2006 data sets were gathered from the California Employment Development
Department (EDD) Labor Market Information Division. Payroll establishments were used as a proxy for
businesses that could potentially be hiring employees.
o Both Kern and Fresno have far fewer employment opportunities within the BHC communities
as approximated by the very low percentage of payroll establishments compared to the
respective County total percentage and overall SJV percentage.
Conclusions
This preliminary report identifies some possible baseline indicators from existing data sources that can be used
to measure the “Four Big Results” and associated outcomes for the San Joaquin Valley BHC sites. This is
intended to begin the conversation on whether and how currently collected and readily available data sources
could be used and exemplify the kinds of additional measures that might be derived from new data collection in
the BHC places. This preliminary report identifies a number of issues that may need to be considered in during
the planning process.
(1) Geographic Identification: Most of the relevant secondary data sources that we could identify to
measure key BHC outcomes were available by zip code and not by census block. Since the BHC places
are defined by census blocks and include portions of multiple zip codes, it is not possible to exactly link
most measures to the place. There will need to be problem-solving about whether or not indicators that
reference a larger area are acceptable to monitor progress on BHC goals. TCE has developed a method
for zip-code approximations of the places that will be useful as more data are identified and explored.
(2) Additional Secondary Data: Additional data sources of data may exist for some indicators. For
example, the Healthy Kids Survey may be a good data source to augment the obesity and fruit and
vegetable consumption findings with fitness and physical activity data, but may be difficult to use
without obtaining school level data. This source also includes other indicators of youth health that may
be relevant such as use of alcohol, drugs, and tobacco. It does not include more detailed data on
insurance status, access to care, or receipt of preventative services.
(3) Difficult to Access Secondary Data: Collaboration with other institutions may be required to obtain
additional data measures to address obvious gaps in this report (i.e., violence, crime, Healthy Kids,
Medi-Cal, and CHI enrollment data). Many of the most relevant indicators would require special,
potentially time-consumimg and expensive, analyses of larger data sets maintained by state or county
governments. Crime data specifically at the BHC place level would require special analyses by county
public safety officials, while Medi-Cal enrollment within the BHC place may require special analyses of
existing state data.
14
(4) Importance of Perception and Understanding: For many of the Outcomes, it may be necessary to
obtain supplementary subjective and individual-level perception and behavior data from surveys or
service use to meaningful reflect the baseline and subsequent progress. For example, having access to a
health home is in part about residents’ perceptions and experiences as about data indicating coverage.
Similarly, objective crime indicators may not accurately reflect the expereinces of safety. Some of these
perception measures (safety, access) will be available in the future from CHIS for the Valley places
through the planned over-sampling of these areas.
(5) Obvious Available Data Indicators Did Not Exist: For at least two of the Outcomes, we could not
identify existing data or the most appropriate indicators. For Outcome 9, we did not identify secondary
data sources at the BHC place level, that also offerred a range of health status measures broken out by
both race/ethnicity and age. Similarly for Outcome 10, we did not identify an objective or subjective
indicator for statewide consensus on a vision for healthy communities. Again it is possible that the
expanded CHIS data will permit this. The Healthycities web-site does include some approximations for
these measures, based on combining multiple years of CHIS data, but small original samples and the
high standard errors in the approximated data make comparisons between places or between
race/ethnicity and gender groups within places hard to interpret.
(6) Long-term and Interim Outcomes Indicators: Many of the indicators appear to refer as much to a
change in policy and practice by governments, agencies, and community members as a change in
quanitative indicators of community perfomance. Particularly in domains such as childhood obesity and
school attendance, there may be a significant time delay between changing policies, practices and
environments, as well as changing overall community performance. This suggests the need to achieve
consensus on interim measures to reflect capacity building, development of model programs that are
not-to-scale, and policy and systems changes that lead to outcomes.
In conclusion, we sought to assist the Valley BHC planners by offering new ways to think about the Big Results
and the objectives, strategies, and indicators that are being developed. While examining these preliminary data
collection and ongoing organizational efforts to conceptualize the TCE Four Big Results and associated
outcomes, we recognize many measures proposed and data found raise as many questions as they answered.
We would like to engage other interested stakeholders in the SJV BHC sites and other regional organizations in
ongoing discussions to determine what it would look like to achieve these results in our region and how we
should go about measuring our successes in our policy and systems change efforts.
15
Appendix A – Methods and Data
BHC Areas defined
The SJV BHC sites contain all or part of the following zip codes:
1. Fresno (93701, 93702, 93706, 93721)
2. Kern (93203, 93307, 93241)
3. Merced (95333, 95340, 95341, 95365)
All demographics and health indicators presented in the data tables (Tables 2 & 3) are reported at the BHC zip
code level. These zip code data are the closest match to the BHC places, which are defined by census blocks as
many of the available data elements are at the zip code level and overlap considerably with the SJV BHC sites.
Additionally, data from a Community Cluster household telephone survey (n=1,100) was conducted in 2009
covering Fresno (n=120) and Kern (n=120) BHC sites.
Demographics
The following two demographic data sources were used in this report:
1. Nielson Claritas – U.S. Census-based and annually adjusted demographic data are presented in Table
4. 2009 demographic data for the SJV BHC sites in this report were acquired from The California
Endowment (maps.calendow.org)
•
Claritas data suggest that the percentage of county population contained in the BHC sites is
similar for Fresno and Kern and almost twice as much for Merced. It is noteworthy to point
out that the Fresno and Kern BHC sites represent smaller and more concentrated proportion of
the county, while the Merced BHC site is comparatively larger making up almost 25% of the
county. Population density is also extremely high in the three BHC sites compared to the rest
of their respective counties due to the large amount of rural and mountainous areas that make
up much of the three San Joaquin Valley counties in this report.
• Fresno and Kern BHC sites have a lower median household income, a higher percentage of
Hispanic population, a younger population and more households with children than their
respective counties.
•
The Merced BHC site has a lower median household income, a higher percentage of Hispanic
population and a similar age of population and households with children than Merced County.
• Overall both the BHC and County data compares poorly with State data in that the BHC sites
and the Counties are poorer, with a higher percentage of Hispanics, a younger population and
have a higher number of households with children than when compared to State numbers.
2. San Joaquin Valley Community Cluster Survey - The Social Research Lab of the California State
University, Fresno administered a CVHPI-designed Community Assessment telephone survey in 2009.
16
Data from approximately 120 residents from each cluster were collected. Collected cluster data
addressed:
•
•
•
•
Community demographics
Social connectedness
Overall health (i.e., general well-being, depression, diagnosed chronic diseases, and selfefficacy)
Chronic disease indicators (i.e., obesity, fruit and vegetable intake), and neighborhood
environment (i.e., disadvantage scale and safety)
Survey demographics indicate a parallel relationship of poverty with the Census-derived
data among the BHC sites. Median household income ranged from $24,386 to a high of
$43,040
The community survey data indicate a slightly different demographic finding that may be
attributed to selection bias of those surveyed. The survey shows that nearly three fourths of
the BHC clusters responded were females and predominantly Hispanic in Kern.
Health indicators
All SJV health indicator data were obtained from the CVHPI-maintained data warehouse. This data warehouse
contains all county vital statistics (births, deaths, hospitalizations) data sets for the SJV counties:
• Birth Statistical Masterfiles (not used in this report) – (1998-2006)
• Death Statistical Masterfiles - (1999-2005)
Office of Statewide Health Planning and Development (OSHPD) hospitalization data were obtained and
include:
• Hospitalization discharge data – (1998-2006)
Just about all health indicator data in Table 4 are expressed as population-adjusted rates. All vital statistics data
were obtained from the California Public Health Department Office of Vital Statistics.
17
Appendix B - Avoidable Hospital Conditions
Adults (ages 20+ years)
• Diabetes short-term complication admissions
• Perforated appendix admissions
• Chronic obstructive pulmonary disease admissions
• Diabetes long-term complication admissions
• Hypertension admissions
• Congestive heart failure admissions
• Low birth weight
• Dehydration admissions
• Bacterial pneumonia admissions
• Urinary tract infection admissions
• Angina without procedure admissions
• Uncontrolled diabetes admissions
• Adult asthma admissions
• Lower-extremity amputation among patients with diabetes
• Foreign body left in during procedure
• Latrogenic pneumothorax
• Selected infections due to medical care
• Post-operative wound dehiscence
• Accidental puncture or laceration
• Transfusion reaction
• Post-operative hemorrhage or hematoma
• Laminectomy
• Hysterectomy
Pediatric (0-19 years)
• Asthma
•
Short-term complications of diabetes
•
Gastroenteritis
•
Urinary tract infection
•
Perforated appendix
18
Appendix C – Schools Serving BHC places included in Fitnessgram Data
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
Academy Charter
Arvin High
Buhach Colony High
Cambridge Continuation High
Carver Academy
Cesar Chavez Middle
Design Science Early College High
Dewolf Continuation High
Edison Computech
Elizabeth Terronez Middle
Golden Valley High
Greenfield Middle
Haven Drive middle
Herbert Hoover Middle
J.E. Young Academic Center
Kings Canyon Middle
Le Grand Union High
Leon H. Ollivier Middle
McKee Middle
McLane High
Merced High
Mountain View Middle
Roosevelt High
School of Unlimited Learning
South High
Sunnyside High
Sunset
Tenaya Middle
Weaver Middle
Yosemite Middle
19